Life Enhancement Psychotherapy, LLC is an outpatient private practice that I founded in Hanover, MA, during 2007. I currently employ three clinicians and our focus is the provision of individual, couples, and family therapy. This summer we will launch our wellness program with a series of psychoeducational seminars. The first seminar will focus on dating and building healthy intimate relationships, the second will focus on esteem and peer relationships for adolescents, the third seminar aims to support couples looking to have their first child or expand their family. In addition to providing clinical and psychoeducational services, I am in charge of clinical supervision, administrative services, program development and marketing.

1) In your experience, what is the public perception of dissociative disorder (DD)? It was once known as “multiple personality disorder,” yes? What led to the name change?

The syndrome that is known today as dissociative identity disorder (DID) has been redefined in almost every edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM); in addition to MPD, the terms, dissociative reaction, hysterical neurosis (dissociative type) were formally used to denote the disorder. DID replaced MPD with the introduction of the fourth edition of DSM 1994. The name change corresponds with the Manual’s increased emphasis on the use of empirically based materials in defining and categorizing mental disorders. More specifically, empirical literature suggests that the key underlying difficulty with the disorder is a disruption in integrative consciousness; in the case of DID this disruption is of such severity that the person takes on one of more new identities. This marked disintegration of integrative consciousness arguably makes DID the most extreme of the five Dissociative Disorders.

Broadly speaking, the public is well aware of the existence DID although many tend to be misinformed regarding the actual symptoms and features of the disorder. On several occasions I have had a client state that s/he or a loved one must have DID because of chronic and severe changes in mood; as it turns out they are typically describing chronically labile affect (i.e., “moodiness”) or, in more severe cases, Major Depressive Disorder or Bipolar Disorder. Similarly, a common mistake of my undergraduate students is to confuse DID with schizophrenia. As far as I can tell, the confusion is associated with the perception that both are severe mental illnesses that are associated with fundamental changes in self, relatedness to others and the world. Students often note that both DID and schizophrenia evoke a bit anxiety as disorders that they would never want to encounter or personally develop.

2) What percentage of patients is diagnosed with DD? Is it rare, or more common than people would think?

The exact prevalence of DID is matter of controversy. The difficulties associated with determining prevalence of DID stem from various clinical sources. While the disorder was initially considered rare, during the 1970s and 1980s there was a spike in reported cases. Some clinicians and researchers argued that greater awareness of the disorder was leading to improved accuracy in diagnosis and reported cases, others argued that many cases were inaccurately identified. One common observation is that many clinicians do not encounter DID ever in the span of their careers where as a relatively small number of clinicians appear to encounter the large majority of cases. It is not clear if differences in training, clinical setting or other variables explain the discrepancy among clinicians diagnosing the disorder.

3) This is going to seem like a painfully basic question, but DD is often featured in movies: How accurate are portrayals like Sybil or Three Faces of Eve? Did those films perpetuate an inaccurate perception? What would be more true to life?

The 1976 version of Sybil and Three Faces of Eve are useful in that they first introduced DID to lay populations. I sometimes suggest viewing Sybil to students enrolled in my Abnormal Psychology and Psychological Trauma courses with the goal of helping them understand the definition of “severe and horrific abuse”. The terms “abuse” and “trauma” are used in such a trivialized fashion in popular culture that students (and the public) sometimes become insensitive to the true meaning of such terms. Sybil is useful in helping individuals move beyond popularized notions of trauma to see that DID is an unconscious survival tactic enlisted by the mind in response to inescapable stress which is of such severity that it threatens the victim’s psychological and/or physical integrity. The emergence of DID is the mind’s attempt to create a stronger self that can cope with such stress and thereby save the victim from perceived threat of annihilation. Such films, Sybil in particular, are also useful in demonstrating the client’s subjective experience of distress in response to the disruptive symptoms of disorder during adulthood and the decompensation experienced when the defenses that created the alternate identity states are challenged and start to fail.

Drawbacks of films such as Sybil and Three Faces of Eve include a glamorization of DID in that each presents a physically attractive, vulnerable yet courageous lead character who, despite the trials of her past and hardships associated with having DID, ultimately triumphs over the disorder. Apparently, this notion is so appealing that modern soap operas recurrently make DID and other Dissociative Disorders a common occurrence in their plots. In these cases DID often is almost entirely unplugged from their foundation in traumatic stress and instead are the product of mind manipulation by a villain or a devious situation. While entertaining, such media contributes to public misperceptions regarding the disorder as being relatively common and having a time limited and circumscribed impact on one’s life. Perhaps a more significant concern in clinical settings is that film’s depiction of DID has, for some clients, created an idealized picture or an individual suffering from a severe mental illness. In response, some clients engage in diagnosis seeking in which they either openly or covertly attempt to convince the therapist that she or he has DID. In their minds having DID places them in the company of characters such as Sybil and Eve; this is at the cost of recognizing, accepting and working through difficulties that may not at all represent DID. When I have encountered such clients, a major barrier to treatment has been a sometimes ardent stance regarding having the disorder and, in the most severe of cases, conscious feigning of symptoms (i.e., stating that the client is unavailable for therapy, an adult act as if she or is a child in session).

4) Some of the research I’ve seen shows that doctors were skeptical of DD in the 1980s—skeptical that it was considered a disorder at all. Has that changed in recent decades? Is it is now accepted? Why now and not then?

Clinical debate regarding DID as a legitimate disorder stems from several sources. One source is theoretical growth in field of clinical psychology. While analytic and psychodynamic models were prevalent in the field and in early conceptualizations of DID during the 1940s and 50s, newer competing theoretical models such as behaviorism and social learning were introduced and gained popularity starting in the 1970s. Some proponents of these alternate models suggest that DID is not the product of unconscious influences of the mind as suggested by dynamic models. Instead, they conceptualize DID as the product of behavioral learning or adoption of a role in an unhealthy family system. From these perspectives, DID does not represent the presence of classically defined, dynamic personality states but instead is largely the product of environmental influences. While the debate between varied theoretic perspectives has calmed, the controversy has never been resolved.

Other challenges are clinically oriented. A frequently discussed difficulty is that people diagnosed with DID also tend to be highly suggestive; that is, they are relatively open to the influence of others, they are relatively open to hypnotic states and related suggestion. Some cases of the DID may actually have been inadvertently induced by therapists suggesting the presence of one of more separate identity states. Similarly, treatment of DID often involves mental revisiting of childhood trauma; recall of childhood memories commonly includes distortions and also may also be highly malleable in therapy. Such a lack of reliability in memory and openness to mental distortions contributed to some clinicians and researchers doubting to validity of DID.

While DID continues to present challenges diagnostically, in competing theoretic perspectives, and popularization in lay populations, the disorder has sufficient empirical validation to support continued inclusion in DSM. A major goal in the production of the current DSM (DSM-IV-TR) was the use of empirically supported data in determining which disorders should be included in current nomenclature. Structured interviews designed to differentiate disorders support DID as a specific and valid mental disorder that can differentiated reliably from other disorders. Specific placement of DID in the Dissociative Disorders category, should foster continued scholarly interest and further empirical research that will assist in clearing up controversies associated with the disorder. Lastly, clinical research has assisted in better delineating features of the disorder as well as providing clinical tools that assist clinicians in avoiding diagnostic pitfalls and problems associated with inadvertently influencing client memories.

5) If you can, speak to me a little about DD’s use as a criminal defense. What do people have to prove in order for it to be an effective defense? How hard is it? How easy is it?

I am not a forensic psychologist and I cannot comment specifically on the use of DID as a criminal defense although the clinical challenges discussed in question two are almost certainly of relevance in forensic settings.

6) What, in your opinion, is the most important skill for a licensed psychologist to have when treating someone with DD? Is there additional training that psychologists must have to treat these patients?

Ideally, inclusion of patients suffering from DID should be included in graduate training if the clinician intends to treat the disorder post graduation. Additionally, I would recommend continued building of a strong academic and clinical background in treating severe and chronic mental illness, particularly those that emerge in response to psychological trauma. When starting out with treating DID or similarly severe disorders, supervision by one or more experienced clinicians is especially important. While not required, engaging in on-going training is recommended so as to keep clinicians apprised of advances in treatment and empirical understanding of the disorder.

7) What is the best approach to treatment? Is there a cure?

I cannot definitively comment on a “best” approach to treatment because disagreement persists among clinicians with reference to theoretical perspective and ensuing approach to treatment. Additionally, every client and his or her needs differ and this must be taken into account when formulating treatment. More broadly speaking, one of the most common approaches to treating DID is psychodynamic in which the primary goals are assisting the person with integrating personality states via gaining insight regarding their experiences of trauma and the impact of such experiences on development of self. In such an approach the client-therapist relationship is essential in creating a sense of safety in which the client can psychologically re-tell their experiences and gain insight regarding the manner in which the mind created differing identity states as an attempt at coping and survival. Ultimately, in dynamic treatment the process of exploration includes the building of coping skills that may eventually replace defenses that cause the emergence of multiple identity states.

8) What is the typical age range of patients? How young can a child be diagnosed? How old can someone be as a first-time patient with DD?

It is believed that DID frequently develops during childhood although the disorder may go undiagnosed. Limited language and communication skills of children as well as their tendency to engage in imaginative play may contribute to limited recognition of DID symptoms in lay and professional populations.

Most commonly DID is diagnosed during adulthood and approximately three-quarters of patients are women. There is no upper age limit in diagnosing DID although it is believe that symptoms may abate as on enters middle age; this may be the product of mastery over one’s environment and variables that may trigger the emergence of alternate identity states.

9) What are the proverbial red flags for family members to watch for? Is DD genetic?

Current data suggest that in comparison to the general population there may be a higher rate of DID among first degree biological relatives of individuals who carry the diagnosis; the reasons for the increased numbers are not clear. Conversely, it is widely agreed that environmental factors, namely severe and chronic abuse, are risk factors for the development of DID. Given the relationship between child abuse and DID it is advisable that family members, teachers or other individuals who are in regular contact with young children watch for common indicators of child abuse such as frequent, unexplained bruises or lacerations, uncommonly sophisticated sexually explicit themes in play, marked and unusual anxiety and fear responses. By looking for these more common signs of physical abuse, adults may play a role in protecting children from the exposure to violence that is typical of DID as well as a broad array of other undesired outcomes.

10) What are the most prevalent behaviors exhibited by someone with DD and can they ever be mistaken for something else?

DID refers to the presence, in one individual, of two or more separate identity states which take turns controlling the individual’s behaviors. The alternate identities often have contrasting characteristics, for example, one may be socially withdrawn while the other(s) may be outgoing, domineering or even aggressive toward others. It is possible for alternates to have differing physically-related variables so that one may have allergies, the other(s) may not, one may have asthma, need glasses, or have a speech impediment while the other(s) may not. The personal and family history as told by each alternate may differ dramatically and the alternate identities may not have awareness of each other. Given the marked range of variations in alternates, it is easy to overlook or misdiagnose DID. For example, a client presenting with complaints of hearing voices giving commands or a running commentary may be demonstrating a symptom of DID or the client may be suffering from schizophrenia or another psychotic disorder. Complaints regarding “losing time” may represent symptoms of DID, another Dissociative Disorder, Posttraumatic Stress Disorder, Acute Distress disorder or in some cases, even Depersonalization or another Somatic Disorder.

11) Is there a story the media is grossly missing about DD? Is there a message you feel is of import for psychologists and parents?

Nothing comes to mind….

Please feel free to share any other thoughts I might've overlooked or forgotten to ask, and thank you so, so much for your time.